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Behavioral Health Stakeholder Advisory Committee Meeting

July 16, 2020

• Please use either computer or phone for audio connection.

• Please mute your lines when not speaking.

• For questions or comments, email: BehavioralHealthSAC@dhcs.ca.gov

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Webinar Tips

Welcome and Introductions

Budget Updates

COVID-19 Updates: Telehealth

• Comprehensive policy update was implemented in summer 2019 after extensive stakeholder engagement.

• Licensed providers have flexibility to determine if service delivery is appropriate for audio-visual, two-way communication or store-and-forward.– Physicians, nurses, mental health practitioners, substance use

disorder providers, dentists, Federally Qualified Health Centers, Rural Health Clinics, Indian 638 clinics, and other licensed providers may use telehealth

– Beneficiaries retain choice for service delivery modality • E-Consults allowed for licensed providers

– Not available for FQHCs, RHCs, and Indian 638 clinics• Modifiers used with claims to indicate if the service is provided for

synchronous or store-and-forward services.

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Medi-Cal Telehealth Policy

• During the public health emergency (PHE), DHCS will pay the same rate for telephonic services as face-to-face under the following circumstances:– Encounter must meet the requirements of billed visits that would

have otherwise been provided in a face-to-face encounter – The encounter replaces a face-to-face visit– Service is clinically appropriate for modality used– Service provided meets all procedural and technical components

of the service• Applies to all provider types, including Federally Qualified

Health Centers (FQHC), Rural Health Clinics (RHC), and Tribal 638 clinics.

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Virtual/Telephonic Communication During PHE

• Home of the beneficiary can serve as an originating site.

• Use of telephonic visits without visual of beneficiary.

• Establishment of a new patient via telehealth with visual of beneficiary.

• DHCS will review these PHE flexibilities to determine which ones should be permanent provisions, and whether federal approvals are necessary.

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Virtual/Telephonic Communication Flexibilities During PHE (cont.)

• Can receive their Prospective Payment System rate or All-Inclusive Rate for telephonic services that meet billed visit requirements.

• Can bill with HCPCS code G0071 for virtual/ telephonic services that do not meet visit requirements.

• Associate marriage and family therapists and associate clinical social workers can be billable providers in FQHCs and RHCs.– This is currently allowed for Tribal 638 clinics

• Tribal 638 clinics can provide services outside of the four walls and still receive reimbursement.

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Flexibilities for FQHC, RHC, and Tribal 638 Clinics During PHE

• Medi-Cal enrolled dentists and allied dental professionals (under the supervision of a dentist) may render limited services via synchronous/live transmission teledentistry, so long as such services are within their scope of practice.

• For dental services provided via teledentistry, providers are to use appropriate billing code based on the telehealth modality used –synchronous or store-and-forward.

• Dental providers will be reimbursed based upon the applicable CDT procedure code according to the Schedule of Maximum Allowance (SMA).

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Teledentistry

• Effective March 25, 2020, a temporary teledentistry exception was implemented to allow for dental providers who provide consultation services by telephone or video to remote Medi-Cal members.

• Providers may use CDT code D9430 in lieu of an in-person visit for purposes of live streaming video or telephone with a Medi-Cal patient with oral health issues.

• Providers would be reimbursed the SMA rate for CDT code D9430 plus applicable transmission fees, as appropriate. 11

Teledentistry (cont. slide 2)

COVID-19 Updates: Medi-Nurse Line

• Medi-Nurse line offers 24/7 advice for people without health insurance or who have fee-for-service Medi-Cal but don’t have a regular doctor to oversee their care.

• Medi-Nurse is not designed for callers who already have a health plan that covers COVID-19 services.

• Accessed by calling 1 (877) 409-9052.– Available in multiple languages, through

LanguageLine (Spanish +17 additional languages)

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Medi-Nurse Line: Overview

• All callers can ask general questions about COVID-19 symptoms, and get additional information about and referrals to helpful COVID-19 resources.

• All callers who present with COVID-19 symptoms will also have access to trained and knowledgeable nurses for clinical consultation and triaging, including but not limited to:‒ Directions to self-isolate and perform home self-care

techniques.‒ Directions to get tested and/or seek treatment, inclusive of

referrals to COVID-19 resources such as information relative to testing sites using the locator tool via COVID19.ca.gov.

• Uninsured callers will also be referred to a qualified provider in the county of the caller who can perform presumptive eligibility (PE) determinations to provide temporary coverage to minimally obtain COVID-19 testing, testing related and treatment services.

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Medi-Nurse Line: Overview (Cont.)

Note: QP refers to Qualified Provider

Impact of Medi-Nurse Line (May 2020 to current):• 11,000+ Calls • 2% Abandonment Rate (better than industry standard of 5-

8%)• 81% Uninsured• 52 (90%) California counties serviced

Medi-Nurse Line Statistics

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Medi-Nurse Line Statistics (cont.)

43% 43% 37%57% 57% 63%

0-20 21 - 64 65+

Age Group and Gender

57%

78%

21%

1%Language

English

Spanish

OtherLanguage

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Medi-Cal 2020 Section 1115 Waiver Update

• Medi-Cal 2020, California Advancing and Innovating Medi-Cal (CalAIM), and COVID-19

• Plan for 12-Month 1115 Waiver Extension Request–Programs not included in the extension request–Programs included in the waiver extension

request• Financing and Budget Neutrality• 1915(b) Specialty Mental Health Services Waiver

– second extension request• Timeline and Next Steps

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Overview

• The current 1115 waiver (Medi-Cal 2020) is set to expire on December 31, 2020.– Prior to the COVID-19 public health emergency, DHCS planned to

implement CalAIM in conjunction with the end of the waiver period• COVID-19 has greatly impacted all aspects of California’s health

care delivery system, due to focus on surge planning, infection control, transition to telehealth/telework, and reprioritization of resources.

• Health care systems, plans, providers, and counties requested a delay in CalAIM, due to the need to address the pandemic.

• While the state is still committed to CalAIM, an extension of the Medi-Cal 2020 waiver is crucial to maintaining the current delivery system and services for beneficiaries.

• The final FY 2020-21 state budget reflected a delay in funding for CalAIM.

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Medi-Cal 2020, CalAIM, and COVID-19

• DHCS must request a waiver extension from CMS in order to keep Medi-Cal 2020 from expiring on December 31.

• 12-month extension will provide the necessary federal authority and Medicaid matching funds.– Support the financial viability of the delivery system in the

context of COVID-19• Waiver extension proposal to be released for public

comment on July 22.– 30-day comment period will close on August 21– Goal to submit 1115 Extension request to CMS by

September 15

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Medi-Cal 2020 12-Month Extension Request

• Medi-Cal Managed Care• Whole Person Care• Global Payment Program • Drug Medi-Cal Organized Delivery System• Low-Income Pregnant Women• Former Foster Care Youth• Community-Based Adult Services• Coordinated Care Initiative• Dental Transformation Initiative & Designated State Health

Programs (DSHP)• Tribal Uncompensated Care• Rady’s CCS Pilot

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Components of Medi-Cal 2020 Waiver Extension Request

• Public Hospital Re-Design and Incentives in Medi-Cal (PRIME)–PRIME reporting metrics and funding to be transitioned to Medi-Cal managed care Quality Incentive Payment (QIP) program

–Request submitted to CMS in early 2020

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Components NOT included in Extension Request

12-Month Extension Key Elements

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• Continue WPC Pilot Program as currently structured.

• Additional year of funding at FY 2019-2020 (PY 4) expenditure levels.

• New target population for individuals impacted by COVID-19.

• Allow WPC pilots to modify their budgets in response to COVID-19.

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Whole Person Care

• 12-month extension of authority and federal matching funds for: –Global Payment Program extended to

December 31, 2021–Safety Net Care Pool/UCC funding

continues

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Global Payment Program and Dental Transformation Initiative

• 12-month extension of authority for county-based pilots, including expenditure authority for residential SUD services in IMDs; Medi-Cal funding.

• Technical changes: – Remove limitation on the number of residential treatment

episodes that can be reimbursed in a one-year period – Clarify that reimbursement is available for SUD assessment

and appropriate treatment even before a definitive diagnosis is determined

– Clarify the recovery services benefit– Expand access to MAT– Increase access to SUD treatment for American Indians and

Alaska Natives

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DMC-ODS

• Low-Income Pregnant Women: Extension; No changes• Former Foster Care Youth: Extension; No changes• CBAS: Extension; No changes except temporary COVID

provisions attachment• CCI: Extension; No changes• Dental Transformation Initiative: Extension including

Designated State Health Programs mechanism; transition to State Plan in 2022; Discontinue Domain 4

• Tribal Uncompensated Care Waiver Amendment: Extension; Requirement for CRIHB to contract with any willing Tribal health program enrolled in Medi-Cal

• Rady’s CCS Pilot: Extension; No changes

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Other Programs in the Extension Request

• Whole Person Care: Requesting an additional year ($300 million) of federal funding equal to 2020 program (PY4) expenditures

• GPP: Continued FFP for value-based payments to participating Public Health Care Systems that incur costs for services to the remaining uninsured

• Budget Neutrality: Request to continue treatment of following expenditures to eliminate impact to calculation – DMC-ODS– CBAS – Health Homes– Out-of-State Former Foster Youth– Managed care payments for the ACA new adult expansion

population– Hospital Quality Assurance Fee program related payments

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Financing

1915(b) Specialty Mental Health

Services Waiver Extension

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1915(b) Specialty Mental Health Services (SMHS) Waiver Extension

• On May 8, 2020, DHCS formally requested an extension of the state’s current Medi-Cal SMHS Waiver authorized under Section 1915(b) of the Social Security Act.

• As originally approved by CMS, this 1915(b) waiver was set to expire on June 30, 2020.

• DHCS requested CMS’ approval to extend the term of the waiver through December 31, 2021.

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1915(b) Specialty Mental Health Services (SMHS) Waiver Extension (continued)

• On June 2, 2020, DHCS received a response from CMS approving a six-month extension to December 31, 2020, acknowledging the need for an additional extension request due to the delay of CalAIM.

• DHCS is now seeking a second extension to the 1915(b) waiver to December 31, 2021, to coincide with DHCS’ extension request for the 1115 waiver.

• Public Comment– The 30-day public comment period will start on July 22, 2020– Waiver extension request & all other documentation will be posted on the

DHCS website– Comments made at public meetings will be transcribed– Written comments can be submitted to 1115waiver@dhcs.ca.gov by COB

on August 21, 2020– Written comments on the 1915(b) waiver extension can be submitted to

MCBHD@dhcs.ca.gov by COB on August 21, 2020

• Tribal Consultation (held via webinar)– Wednesday, July 29, 2020

• Public Hearings (held via webinar)– Friday, August 7, 2020 3:30 p.m. – 5:00 p.m.– Monday, August 10, 2020 2:00 p.m. – 3:30 p.m.

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Next Steps

Questions and Comments

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CalHOPE: Crisis Counseling Program Update

• $1.6M awarded from FEMA to re-launch CalHOPE – used in Camp Fire disaster

• Media campaign to normalize feelings of stress, anxiety and reduce depression during the pandemic and refer to website and Warm Line

• CalHOPE website -www.calhope.dhcs.ca.gov

• CalHOPE Warm Line - (833) 317-HOPE7/14/2020 35

Crisis Counseling ProgramImmediate Services Program

• Media Impressions:– Digital outreach – 12 million– Television – 89 million– Chinese language content – 10 million

• Actions– 92% of 2.3 million people that clicked on video

watched the entire video– 1.6 million impressions on pre-roll with view

completion rate (VCR) of 92.15% – 9,400 people took actionable steps– Spanish language response was twice general

market rate

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CalHOPE Media Outreach

• 26,299 visits• 16,314 new users• Average time on site - 2:10• Chinese display ad generated over 6,000

visitors

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CalHOPE Website VisitsFrom June 6 – July 7

• Currently M-F 7 a.m. – 11 p.m.• Outside hours menu option for CA Peer

Run Warm Line • 334 calls less than 15 minutes• 110 calls over 15 minutes

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CalHOPE Warm Line

Virtual Tour

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Children and Youth Access to Behavioral Health Services: Background and Discussion

• Right care, right time: Every child or youth with behavioral health needs will have timely access to high quality care

• Meet needs of children and youth in foster care: Ensure coordinated, cross-system, trauma-informed health care for children in the child welfare and foster care systems

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Goals

Payment Reform: • Building blocks to tie value to payment and ensure

financially sustainable system of careIntegration:

• Allowing better care for youth with co-occurring disorders

Medical Necessity:• Address barriers to treatment, improve coordination

between managed care and specialty mental health, allow services prior to diagnosis, and ensure Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services protections

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CalAIM: Opportunities to improve care for children

and youth

• During pandemic: Ensure maximum flexibility to provide children and youth access to services.

• Post-pandemic: Leverage what we learned to keep what works, and keep building on improvements.

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Building on telehealth progress

• Holding counties and managed care plans accountable to standards for access and quality through multiple metrics:– Time & Distance– Timeliness of Appointments and Services– Provider Ratios– Penetration Rates– Grievance & Appeals– CMS* Core Set and other Quality Measures

• Developing a public mental health dashboard; SUD dashboard in development.

* CMS: Centers for Medicare & Medicaid Services 45

Metrics: Ensure accountability for access

• Tools are used to assess baseline and determine response to treatment over time.

• Currently working to develop a reporting and oversight infrastructure, which could include:– Analyze functional assessment and utilization data to

assess treatment effectiveness by county and statewide (by age, race, gender, primary language etc.).

– Perform comparative analyses of counties and work with counties on improvement projects.

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Functional assessments:Child and Adolescent Needs and Strengths (CANS)

Pediatric Symptom Checklist (PSC)

• AB 2083: Better coordinate between county and state agencies, focused on trauma-informed practices.

• Therapeutic Foster Care: Implement and scale model (as of June 2020, there are 12 TFC providers approved and 11 providers awaiting Medi-Cal Certification).

• Pathways to Well-Being (Katie A.): Ensure children and youth have access to coordinated and intensive home-based treatment services.

• Family Urgent Response System: Implement statewide hotline and county mobile response to allow prompt intervention and issue resolution for children, youth in foster care and their families.

• CalAIM Foster Care Model of Care Workgroup: Evaluate options for better and more reliable health care for children and youth in child welfare. 47

Meeting the needs of youth in foster care system

• OPEN FORUM– What else should we consider?– What ideas do you have to improve quality

and access for Children and Youth?

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Improving Behavioral Health Care for Children and Youth

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Public Comment

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Next Steps and Final Comments